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wecuro_blog/application/modules/caregivers/views/new_approval_form.php

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<?php
$documentsarr=array();
$documentsrem=array();
$documentsid=array();
$documentsno=array();
foreach($documents as $document){
$documentsarr[$document->documents_type][]=$document->path.$document->file_name;
$documentsrem[$document->documents_type][]=$document->remarks;
$documentsid[$document->documents_type][]=$document->id;
$documentsno[$document->documents_type][]=$document->documents_no;
//echo '<pre>'; print_r($document); echo '</pre>';
}
$traing_doc_count=count($documentsarr[_DOC_TRAININGCODE_]);
$other_doc_count=count($documentsarr[_DOC_OTHERCODE_]);
$additional_certificate_count=count($documentsarr[_ADDL_CERTIFICATE_]);
?>
<!--sidebar end-->
<!--main content start-->
<style type="text/css">
.required-field:after {
content: "*";
color: red;
}
.verification-tab{
background-color: aliceblue;
}
</style>
<?php if($this->session->flashdata('feedback_error')){ ?>
<script>
Swal.fire({
position: 'center',
icon: 'error',
title: '<?php echo $this->session->flashdata('feedback_error'); ?>',
showConfirmButton: false,
timer: 3500
})
</script>
<?php } ?>
<?php if($this->session->flashdata('feedback_success')){ ?>
<script>
Swal.fire({
position: 'center',
icon: 'success',
title: '<?php echo $this->session->flashdata('feedback_success'); ?>',
showConfirmButton: false,
timer: 3500
})
</script>
<?php } ?>
<div class="app-content content">
<section class="content-wrapper">
<div class="row">
<div class="col-12">
<div class="card" style="height: 13rem;">
<div class="card-header card-header-title-part">
<h3 style="text-align: left;">
Caregiver Information
<span class="float-right mx-2">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span>
</h3>
</div>
<div class="card-body">
<div class="">
<div class="row">
<div class="col-sm-3">
<h6 class="">
<b>Caregiver Id :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-sm-3">
<h6 class="">
<b>Name :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-sm-3">
<h6 class="">
<b>D.O.B :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-sm-3">
<h6 class="">
<b>Caregiver Type :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
</div>
<div class="row">
<div class="col-md-3">
<h6 class="">
<b>Telephone :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Address :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Eye Color :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Hair Color :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
</div>
<div class="row">
<div class="col-md-3">
<h6 class="">
<b>Height & Weight :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Language (s) :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Employee Type :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Hire Date :</b> <span><?php echo $nurse->fname;?> <?php echo $nurse->lname; ?></span>
</h6>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-12">
<div class="card" >
<div class="card-content collapse show">
<div class="card-body card-dashboard">
<div class="col-lg-12">
<ul class="nav nav-tabs nav-linetriangle no-hover-bg pending_tab" id="myTab" role="tablist" style="margin-bottom: 20px; border-radius: 0px;">
<li class="nav-item">
<a class="nav-link <?php if (!$nurse->verification) echo 'active'; ?> " id="INTERNAL-tab" data-toggle="tab" href="#INTERNAL" role="tab" aria-controls="INTERNAL" aria-selected="true">Non Medical</a>
</li>
<li class="nav-item ">
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==2) echo 'active'; ?>" data-toggle="tab" href="#tab8" role="tab" aria-selected="false"> <?php if($progress->form8 < 10){ ?><?php } ?>Medical</a>
</li>
<li class="nav-item ">
<a class="nav-link <?php if (!$nurse->verification) echo 'disabled'; ?> <?php if ($tab==3) echo 'active'; ?>" data-toggle="tab" href="#tab9" role="tab" aria-selected="false"> <?php if($progress->form9 < 10){ ?> <?php } ?>Verifications</a>
</li>
</ul>
<div class="tab-content">
<div class="tab-pane fade <?php if (!$nurse->verification) echo 'show active'; ?>" id="INTERNAL" role="tabpanel" aria-labelledby="INTERNAL-tab" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
<div class="card-body">
<div class="row mb-0">
<div class="col-md-12 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('U.S. WORK AUTHORIZATION & ID');
?>
<span class="float-right">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span>
</h3>
</div>
<div class="card-body">
<div class="">
<?php $citizen = json_decode($nurse->citizen); ?>
<?php //pre($citizen); ?>
<div class="row">
<div class="form-group col-md-12">
<label class="required-field"><?php echo lang('Are you a citizen of the United States? '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input citizen_depending" type="radio" id="citizenyes" name="citizen" open_value="1" change_required_to="us_work_auth" value="1" <?php if (isset($citizen->citizen) && $citizen->citizen==1) { echo "checked"; } ?>>
<label class="form-check-label" for="citizenyes">Yes
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input citizen_depending" type="radio" id="citizenno" name="citizen" open_value="1" change_required_to="us_work_auth" value="0" <?php if (isset($citizen->citizen) && $citizen->citizen==0) { echo "checked"; } ?>>
<label class="form-check-label" for="citizenno">No
</label>
</div>
</div>
</div>
</div>
<div id="us_work_auth" <?php if(!isset($citizen->citizen)){ echo ''; }else if($citizen->citizen==0){ echo ''; }else{ echo 'style="display: none;"'; } ?>>
<div class="form-group col-md-12 ">
<label class="required-field"><?php echo lang('If not, do you have the right to remain permanently and work in the United States? '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input us_work_auth_depending" type="radio" id="remain_permanentlyyes" name="remain_permanently" open_value="1" change_required_to="work_auth" value="1" <?php if (isset($citizen->remain_permanently) && $citizen->remain_permanently==1) { echo "checked"; } ?>>
<label class="form-check-label" for="remain_permanentlyyes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input us_work_auth_depending" type="radio" id="remain_permanentlyno" name="remain_permanently" open_value="1" change_required_to="work_auth" value="0" <?php if (isset($citizen->remain_permanently) && $citizen->remain_permanently==0) { echo "checked"; } ?>>
<label class="form-check-label" for="remain_permanentlyno"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
<script>
$(document).ready(function() {
$(".us_work_auth_depending").click(function(){
var target_val = $(this).val();
var open_value = $(this).attr("open_value");
var change_required_to = $(this).attr("change_required_to");
if(target_val == open_value) {
$("#"+change_required_to).hide();
}else{
$("#"+change_required_to).show();
}
checkBasicCheckList();
});
});
</script>
<?php //if(!isset($citizen->remain_permanently)){ echo ''; }else if($citizen->remain_permanently==0){ echo ''; }else{echo 'style="display: none;"'; } ?>
<div class="form-group col-md-12" id="work_auth" <?php if(!isset($citizen->remain_permanently)||($citizen->remain_permanently==1)){echo 'style="display: none;"'; } ?>>
<label class="required-field"><?php echo lang('Do you have authorization to work? '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="authorization_to_work_yes" name="authorization_to_work" value="1" <?php if (isset($citizen->authorization_to_work) && $citizen->authorization_to_work==1) { echo "checked"; } ?>>
<label class="form-check-label" for="authorization_to_work_yes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="authorization_to_work_no" name="authorization_to_work" value="0" <?php if (isset($citizen->authorization_to_work) && $citizen->authorization_to_work==0) { echo "checked"; } ?>>
<label class="form-check-label" for="authorization_to_work_no"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label class="required-field"><?php echo lang('Are you involved as a defendant in any professional litigation? '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="professional_litigation_yes" name="involved_as_defendant" open_value="1" change_required_to="involved_as_defendant_explain_sec" required_field="involved_as_defendant_explain" value="1" <?php if (isset($citizen->involved_as_defendant) && $citizen->involved_as_defendant==1) { echo "checked"; } ?> required>
<label class="form-check-label" for="professional_litigation_yes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="professional_litigation_no" name="involved_as_defendant" open_value="1" change_required_to="involved_as_defendant_explain_sec" required_field="involved_as_defendant_explain" value="0" <?php if (isset($citizen->involved_as_defendant) && $citizen->involved_as_defendant==0) { echo "checked"; } ?> required>
<label class="form-check-label" for="professional_litigation_no"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-6" id="involved_as_defendant_explain_sec" <?php if((!isset($citizen->involved_as_defendant)) || ($citizen->involved_as_defendant==0)){ echo 'style="display:none;"'; } ?>>
<label class="required-field"><?php echo lang('Explain'); ?></label>
<textarea class="form-control" name="involved_as_defendant_explain" id="involved_as_defendant_explain" <?php if ($citizen->involved_as_defendant ==1 ) {?> Required <?php } ?>><?php
if (!empty($setval)) {
echo set_value('involved_as_defendant_explain');
}
if (!empty($citizen->involved_as_defendant_explain)) {
echo $citizen->involved_as_defendant_explain;
}
?></textarea>
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label class="required-field"><?php echo lang('Have you ever been convicted of a crime? If yes please explain '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="convicted_crime_yes" name="convicted" value="1" open_value="1" change_required_to="convicted_crime_sec" required_field="convicted_crime_explain" <?php if (isset($citizen->convicted) && $citizen->convicted==1) {
echo "checked"; } ?> required>
<label class="form-check-label" for="convicted_crime_yes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="convicted_crime_no" name="convicted" value="0" open_value="1" change_required_to="convicted_crime_sec" required_field="convicted_crime_explain" <?php if ( isset($citizen->convicted) && $citizen->convicted==0) {
echo "checked"; } ?> required>
<label class="form-check-label" for="convicted_crime_no"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-6" id="convicted_crime_sec" <?php if((!isset($citizen->convicted)) || ($citizen->convicted==0)){ echo 'style="display:none;"'; } ?>>
<label class="required-field" ><?php echo lang('Explain'); ?></label>
<textarea class="form-control" name="convicted_crime_explain" id="convicted_crime_explain" <?php if ($citizen->convicted ==1 ) {?> Required <?php } ?>><?php
if (!empty($setval)) {
echo set_value('convicted_crime_explain');
}
if (!empty($citizen->convicted_crime_explain)) {
echo $citizen->convicted_crime_explain;
}
?></textarea>
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label class="required-field"><?php echo lang('Have you ever been convicted for negligence?'); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="convicted_for_negligenceYes" name="convicted_for_negligence" value="1" open_value="1" change_required_to="negligence_sec" required_field="negligence_explain" <?php if (isset($citizen->convicted_for_negligence) && $citizen->convicted_for_negligence==1) {
echo "checked"; } ?> required>
<label class="form-check-label" for="convicted_for_negligenceYes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input activate_depending" type="radio" id="convicted_for_negligenceNo" name="convicted_for_negligence" value="0" open_value="1" change_required_to="negligence_sec" required_field="negligence_explain" <?php if (isset($citizen->convicted_for_negligence) && $citizen->convicted_for_negligence==0) {
echo "checked"; } ?> required>
<label class="form-check-label" for="convicted_for_negligenceNo"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-6" id="negligence_sec" <?php if((!isset($citizen->convicted_for_negligence)) || ($citizen->convicted_for_negligence==0)){ echo 'style="display:none;"'; } ?>>
<label class="required-field"><?php echo lang('Explain'); ?></label>
<textarea class="form-control" name="negligence_explain" id="negligence_explain" <?php if ($citizen->convicted_for_negligence ==1 ) {?> Required <?php } ?>><?php
if (!empty($setval)) {
echo set_value('negligence_explain');
}
if (!empty($citizen->negligence_explain)) {
echo $citizen->negligence_explain;
}
?></textarea>
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label class="required-field"><?php echo lang('Do you have any criminal convictions? '); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input criminal_convictions" type="radio" id="criminal_convictionsYes" name="criminal_convictions" value="1" <?php if (isset($citizen->criminal_convictions) && $citizen->criminal_convictions==1) {
echo "checked"; } ?> required>
<label class="form-check-label" for="criminal_convictionsYes"><?php echo lang("Yes"); ?>
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input criminal_convictions" type="radio" id="criminal_convictionsNo" name="criminal_convictions" value="0" <?php if (isset($citizen->criminal_convictions) && $citizen->criminal_convictions==0) {
echo "checked"; } ?> required>
<label class="form-check-label" for="criminal_convictionsNo"><?php echo lang("No"); ?>
</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-6" id="criminal_convictions_details" <?php if ($citizen->criminal_convictions ==0 ) {?> style="display:none" <?php } ?>>
<label class="required-field"><?php echo lang('Explain'); ?></label>
<!-- <input type="text" class="form-control" name="criminal_convictions_details" id="criminalConvictionsDetailsField" value="<?php
if (!empty($citizen->criminal_convictions_details)) {
echo $citizen->criminal_convictions_details;
}
?>"> -->
<textarea class="form-control" name="criminal_convictions_details" id="criminalConvictionsDetailsField" <?php if ($citizen->criminal_convictions ==1 ) {?> Required <?php } ?>><?php
if (!empty($citizen->criminal_convictions_details)) {
echo trim($citizen->criminal_convictions_details);
}
?></textarea>
<div class="help-block with-errors"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-12 col-sm-12">
<div class="card pending_card" style="height: 13rem;">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('Caregiver Acceptence');
?>
<span class="float-right">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span>
</h3>
</div>
<div class="card-body">
<div class="">
<div class="row">
<div class="col-md-3">
<h6 class="">
<b>Height &amp; Weight :</b> <span>Palta Ambagan Road</span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Language (s) :</b> <span>Palta Ambagan Road</span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Employee Type :</b> <span>Palta Ambagan Road</span>
</h6>
</div>
<div class="col-md-3">
<h6 class="">
<b>Hire Date :</b> <span>Palta Ambagan Road</span>
</h6>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-12 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('Education');
?>
<!-- <span class="float-right">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span> -->
</h3>
</div>
<div class="card-body">
<div class="">
<div class="row">
<table class="table verification-table">
<thead>
<tr>
<th scope="col">School Name</th>
<th scope="col">Location of School</th>
<th scope="col">Degree/Certification</th>
<th scope="col">Graduation Date</th>
</tr>
</thead>
<tbody>
<tr>
<td class="verification-label">ABC</td>
<td class="verification-label">ABC</td>
<td class="verification-label-value"><?php echo $nurse->fname.''.$nurse->lname; ?></td>
<td class="verification-checked">23-09-2015</td>
</tr>
<tr>
<td class="verification-label">ABC</td>
<td class="verification-label">ABC</td>
<td class="verification-label-value"><?php echo $nurse->fname.''.$nurse->lname; ?></td>
<td class="verification-checked">02-09-2014</td>
</tr>
<tr>
<td class="verification-label">ABC</td>
<td class="verification-label">ABC</td>
<td class="verification-label-value"><?php echo $nurse->fname.''.$nurse->lname; ?></td>
<td class="verification-checked">23-09-2015</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="tab-pane fade <?php if($tab==2) {?> active in show <?php } ?>" id="tab8" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
<div class="card-body">
<div class="row mb-0">
<div class="col-md-12 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('Medication');
?>
<!-- <span class="float-right mx-2">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span> -->
</h3>
</div>
<div class="card-body">
<div class="">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="tab-pane fade <?php if($tab==3) {?> active in show <?php } ?>" id="tab9" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
<div class="card-body">
<div class="row mb-0">
<div class="col-md-4 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('NPI Number');
?>
<!-- <span class="float-right mx-2">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span> -->
</h3>
</div>
<div class="card-body">
<div class="form-group ">
<label for="exampleInputEmail1" class="required-field font-weight-bold">
<?php echo lang('NPI Number'); ?>
</label>
<div class="input-group">
<input type="text" class="form-control" name="npi_no" id ="checkNpi_no" value='<?php
if (!empty($setval)) {
echo set_value('npi_no');
}
if (!empty($nurse->verification->npi_no)) {
echo $nurse->verification->npi_no;
}
?>' minlength="10" maxlength="10" placeholder="" onkeypress="return isNumberKey(event)" required data-error="Please enter npi.">
<div class="input-group-append" id="npivalidateTab" style="display: none;">
<span class="input-group-text" >
<span id="npiNoValidating" style="display: none"><i class="la la-hourglass-start" style="color: blue;"></i></span>
<span id="npiValid" style="display: none"><i class="la la-check" style="color: green;">Valid</i></span>
<span id="npiinValid" style="display: none"><i class="la la-close" style="color: red;">Invalid</i></span>
</span>
</div>
</div>
<div class="help-block with-errors"></div>
</div>
</div>
</div>
</div>
<div class="col-md-8 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('Malpractice Insurace');
?>
<!-- <span class="float-right mx-2">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span> -->
</h3>
</div>
<div class="card-body">
<div class="">
<label for="exampleInputEmail1" class="required-field font-weight-bold">
<?php echo lang('Company Name'); ?>
</label>
<input type="text" class="form-control" name="malpractice_comp_name" value='<?php
if (!empty($setval)) {
echo set_value('malpractice_comp_name');
}
if (!empty($nurse->verification->malpractice_comp_name)) {
echo $nurse->verification->malpractice_comp_name;
}
?>' placeholder="" required data-error="Please enter Malpractice Insurance Policy.">
<div class="help-block with-errors"></div>
</div>
</div>
</div>
</div>
<div class="col-md-12 col-sm-12">
<div class="card pending_card">
<div class="card-header card-header-title-part-gray">
<h3>
<?php
echo lang('CPR Certification');
?>
<!-- <span class="float-right mx-2">
<i class="fa fa-pencil" id="card_1_edit" aria-hidden="true" data-toggle="modal" data-target="#updateModal" data-whatever="@mdo"></i>
</span> -->
</h3>
</div>
<div class="card-body">
<div class="">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="tab-pane fade <?php if($tab==4) {?> active in show <?php } ?>" id="tab10" role="tabpanel" aria-labelledby="" style="padding: 20px; border: 1px solid #ccc; margin-bottom: 15px; border-radius: 5px;">
<form role="form" action="<?php echo base_url(); ?>caregivers/saveHapatitisB" id="caregiverBasicForm" method="post" enctype="multipart/form-data" class="needs-validation" >
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
<?php $hbForm=json_decode($nurse->hb_form);
//pr($nurse);die;
?>
<input type="hidden" name="form_tab_status" value="10">
<input type="hidden" name="id" id="caregiver_id" value="<?php if (!empty($nurse->caregiver_table_id)) echo $nurse->caregiver_table_id; ?>">
<input type="hidden" name="form_status" value="10">
<input type="hidden" name="form_mode" value="<?php if($nurse->form_status>0) echo 'Edit'; else echo 'Add'; ?>">
<div class="row">
<div class="form-group col-md-5">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Name'); ?></label>
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
if (!empty($nurse->fname)) {
echo $nurse->fname." ".$nurse->mid_name." ".$nurse->lname;
}
?>' disabled>
</div>
<div class="form-group col-md-5">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('DOB'); ?></label>
<input type="text" class="form-control" id="exampleInputEmail1" value='<?php
if (!empty($nurse->fname)) {
echo $nurse->dob;
}
?>' disabled>
</div>
<div class="form-group col-md-2 mt-2 mt-25">
<!-- <a class="btn btn-primary file-upload" href="<?php echo base_url(); ?>uploads/hb.pdf" target="_blank" download> Download</a> -->
</div>
</div>
<div class="row">
<p> I <?= $nurse->fname." ".$nurse->mid_name." ".$nurse->lname ?> , have been informed of the complication / side effects of receiving Hepatitis B vaccine and I choose to have the vaccine administered to me.</p>
</div>
<div class="row">
<div class="form-group col-md-4">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Allergies'); ?></label>
<input type="text" class="form-control" name="Allergies" id="exampleInputEmail1" value='<?php
if (!empty($hbForm->Allergies)) {
echo $hbForm->Allergies;
}
?>' required>
</div>
<div class="form-group col-md-4">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Date of Exposure'); ?></label>
<input type="date" class="form-control" name="date_of_exposure" id="exampleInputEmail1" value='<?php
if (!empty($hbForm->date_of_exposure)) {
echo $hbForm->date_of_exposure;
}
?>' required>
</div>
<div class="form-group col-md-4">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Location'); ?></label>
<input type="text" class="form-control" name="location" id="exampleInputEmail1" value='<?php
if (!empty($hbForm->location)) {
echo $hbForm->location;
}
?>' required>
</div>
</div>
<div class="row">
<div class="form-group col-md-12">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Type of exposure'); ?></label>
<input type="text" class="form-control" name="type_of_exposure" id="exampleInputEmail1" value='<?php
if (!empty($hbForm->type_of_exposure)) {
echo $hbForm->type_of_exposure;
}
?>' required>
</div>
</div>
<div class="row">
<div class="form-group col-md-12">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Incident Report Completed'); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input" type="radio" id="physicaldefectsyes" name="incident_report" value="1" <?php if ($hbForm->incident_report==1) {
echo "checked"; } ?>>
<label class="form-check-label" for="physicaldefectsyes">Yes
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input" type="radio" id="physicaldefectsno" name="incident_report" value="0" <?php if ($hbForm->incident_report==0) {
echo "checked"; } ?>>
<label class="form-check-label" for="physicaldefectsno">No
</label>
</div>
</div>
</div>
</div>
<div class="form-group col-md-12">
<label for="exampleInputEmail1" class="required-field"><?php echo lang('Worker’s Compensation Report Completed'); ?></label>
<div class="col-md-6">
<div class="row">
<div class="form-check width-80">
<input class="form-check-input" type="radio" id="injuredyes" name="report_completed" value="1" <?php if ($hbForm->report_completed==1) {
echo "checked"; } ?>>
<label class="form-check-label" for="injuredyes">Yes
</label>
</div>
<div class="form-check width-80">
<input class="form-check-input" type="radio" id="injuredno" name="report_completed" value="0" <?php if ($hbForm->report_completed==0) {
echo "checked"; } ?>>
<label class="form-check-label" for="injuredno">No
</label>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<table class="table-responsive">
<tr>
<td>Hepatitis B Vaccine</td>
<td>TYPE</td>
<td>DATE</td>
<td>DOSE</td>
<td>SITE</td>
</tr>
<tr>
<td>Initial Dose</td>
<td><input type="text" name="Initial_Dose_Type" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type)) {
echo $hbForm->Initial_Dose_Type;
}
?>'></td>
<td><input type="date" name="Initial_Dose_Date" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Date)) {
echo $hbForm->Initial_Dose_Date;
}
?>'></td>
<td><input type="text" name="Initial_Dose" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose)) {
echo $hbForm->Initial_Dose;
}
?>'></td>
<td><input type="text" name="Initial_Dose_Site" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Site)) {
echo $hbForm->Initial_Dose_Site;
}
?>'></td>
</tr>
<tr>
<td>Second Dose</td>
<td><input type="text" name="Initial_Dose_Type2" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type2)) {
echo $hbForm->Initial_Dose_Type2;
}
?>'></td>
<td><input type="date" name="Initial_Dose_Date2" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type2)) {
echo $hbForm->Initial_Dose_Type2;
}
?>'></td>
<td><input type="text" name="Initial_Dose2" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose2)) {
echo $hbForm->Initial_Dose2;
}
?>'></td>
<td><input type="text" name="Initial_Dose_Site2" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Site2)) {
echo $hbForm->Initial_Dose_Site2;
}
?>'></td>
</tr>
<tr>
<td>Third Dose</td>
<td><input type="text" name="Initial_Dose_Type3" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type3)) {
echo $hbForm->Initial_Dose_Type3;
}
?>'></td>
<td><input type="date" name="Initial_Dose_Date3" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type3)) {
echo $hbForm->Initial_Dose_Type3;
}
?>'></td>
<td><input type="text" name="Initial_Dose3" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose3)) {
echo $hbForm->Initial_Dose3;
}
?>'></td>
<td><input type="text" name="Initial_Dose_Site3" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Site3)) {
echo $hbForm->Initial_Dose_Site3;
}
?>'></td>
</tr>
<tr>
<td>Booster Dose</td>
<td><input type="text" name="Initial_Dose_Type4" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type4)) {
echo $hbForm->Initial_Dose_Type4;
}
?>'></td>
<td><input type="date" name="Initial_Dose_Date4" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Type4)) {
echo $hbForm->Initial_Dose_Type4;
}
?>'></td>
<td><input type="text" name="Initial_Dose4" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose4)) {
echo $hbForm->Initial_Dose4;
}
?>'></td>
<td><input type="text" name="Initial_Dose_Site4" class="form-control" value='<?php
if (!empty($hbForm->Initial_Dose_Site4)) {
echo $hbForm->Initial_Dose_Site4;
}
?>'></td>
</tr>
</table>
</div>
<div class="col-md-12">
<label><?php echo lang('Lab Work Performed'); ?></label>
<table class="table-responsive">
<tr>
<td>DATE</td>
<td>TYPE</td>
<td>RESULTS</td>
<td>ACTION TAKEN</td>
</tr>
<tr>
<td><input type="date" name="lab_date1" class="form-control" value='<?php
if (!empty($hbForm->lab_date1)) {
echo $hbForm->lab_date1;
}
?>'></td>
<td><input type="text" name="lab_type1" class="form-control" value='<?php
if (!empty($hbForm->lab_type1)) {
echo $hbForm->lab_type1;
}
?>'></td>
<td><input type="text" name="lab_result1" class="form-control" value='<?php
if (!empty($hbForm->lab_result1)) {
echo $hbForm->lab_result1;
}
?>'></td>
<td><input type="text" name="lab_action1" class="form-control" value='<?php
if (!empty($hbForm->lab_action1)) {
echo $hbForm->lab_action1;
}
?>'></td>
</tr>
<tr><td><input type="date" name="lab_date2" class="form-control" value='<?php
if (!empty($hbForm->lab_date2)) {
echo $hbForm->lab_date2;
}
?>'></td>
<td><input type="text" name="lab_type2" class="form-control" value='<?php
if (!empty($hbForm->lab_type2)) {
echo $hbForm->lab_type2;
}
?>'></td>
<td><input type="text" name="lab_result2" class="form-control" value='<?php
if (!empty($hbForm->lab_result2)) {
echo $hbForm->lab_result2;
}
?>'></td>
<td><input type="text" name="lab_action2" class="form-control" value='<?php
if (!empty($hbForm->lab_action2)) {
echo $hbForm->lab_action2;
}
?>'></td>
</tr>
<tr>
<td><input type="date" name="lab_date3" class="form-control" value='<?php
if (!empty($hbForm->lab_date3)) {
echo $hbForm->lab_date3;
}
?>'></td>
<td><input type="text" name="lab_type3" class="form-control" value='<?php
if (!empty($hbForm->lab_type3)) {
echo $hbForm->lab_type3;
}
?>'></td>
<td><input type="text" name="lab_result3" class="form-control" value='<?php
if (!empty($hbForm->lab_result3)) {
echo $hbForm->lab_result3;
}
?>'></td>
<td><input type="text" name="lab_action3" class="form-control" value='<?php
if (!empty($hbForm->lab_action3)) {
echo $hbForm->lab_action3;
}
?>'></td>
</tr>
<tr>
<td><input type="date" name="lab_date4" class="form-control" value='<?php
if (!empty($hbForm->lab_date4)) {
echo $hbForm->lab_date4;
}
?>'></td>
<td><input type="text" name="lab_type4" class="form-control" value='<?php
if (!empty($hbForm->lab_type4)) {
echo $hbForm->lab_type4;
}
?>'></td>
<td><input type="text" name="lab_result4" class="form-control" value='<?php
if (!empty($hbForm->lab_result4)) {
echo $hbForm->lab_result4;
}
?>'></td>
<td><input type="text" name="lab_action4" class="form-control" value='<?php
if (!empty($hbForm->lab_action4)) {
echo $hbForm->lab_action4;
}
?>'></td>
</tr>
</table>
</div>
</div>
<div class="form-group col-md-12">
<button type="submit" name="submit" class="btn btn-info" onclick="return validateForm();"><?php echo lang('submit'); ?></button>
</div>
</form>
</div>
<div class="tab-pane fade <?php if($tab==5) {?> active in show <?php } ?>" id="ACCEPTENCE" role="tabpanel" aria-labelledby="ACCEPTENCE-tab">
<form action="<?php echo base_url(); ?>caregivers/saveApproval" onsubmit="return validateAcceptance();" method="post">
<input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
<input type="hidden" name="caregiver_id" value="<?php echo $nurse->caregiver_table_id; ?>">
<div class="col-md-12">
<table class="table verification-table">
<thead>
<tr>
<th scope="col">Field</th>
<th scope="col">Data</th>
<th scope="col">Action</th>
</tr>
</thead>
<tbody>
<tr><td colspan="3" class="verification-tab">Basic Info</td></tr>
<tr>
<td class="verification-label">Name</td>
<td class="verification-label-value"><?php echo $nurse->fname.''.$nurse->lname; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Mobile Number</td>
<td class="verification-label-value"><?php echo $nurse->phone; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Mobile_Number]" value="Mobile Number">
<textarea name="varify_data[Mobile_Number]" style="display: none;"><?php echo $nurse->phone; ?></textarea>
<input type="hidden" name="varify_file[Mobile_Number]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Email</td>
<td class="verification-label-value"><?php echo $nurse->email; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Email]" value="Email">
<textarea name="varify_data[Email]" style="display: none;"><?php echo $nurse->email; ?></textarea>
<input type="hidden" name="varify_file[Email]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Qualification type</td>
<td class="verification-label-value"><?php echo $nurse->qualification; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[qualification]" value="Qualification">
<textarea name="varify_data[qualification]" style="display: none;"><?php echo $nurse->qualification; ?></textarea>
<input type="hidden" name="varify_file[qualification]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Total years of experience</td>
<td class="verification-label-value"><?php echo $nurse->years_of_exp; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Total_years_of experience]" value="Total years of experience">
<textarea name="varify_data[Total_years_of]" style="display: none;"><?php echo $nurse->years_of_exp; ?></textarea>
<input type="hidden" name="varify_file[Total_years_of]" value="">
</td>
</tr>
<tr><td colspan="3" class="verification-tab">Personal Info</td></tr>
<tr>
<td class="verification-label">Gender</td>
<td class="verification-label-value"><?php echo $nurse->gender; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Marital Status</td>
<td class="verification-label-value"><?php echo $nurse->marital_status; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Dependents</td>
<td class="verification-label-value"><?php echo $nurse->dependents; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Dependents]" value="dependents">
<textarea name="varify_data[Dependents]" style="display: none;"><?php echo $nurse->dependents; ?></textarea>
<input type="hidden" name="varify_file[Dependents]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Date of Birth</td>
<td class="verification-label-value"><?php echo $nurse->dob; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[dob]" value="dependents">
<textarea name="varify_data[dob]" style="display: none;"><?php echo $nurse->dob; ?></textarea>
<input type="hidden" name="varify_file[dob]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Soc Sec</td>
<td class="verification-label-value"><?php echo $nurse->soc_sec; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[soc_sec]" value="soc_sec">
<textarea name="varify_data[soc_sec]" style="display: none;"><?php echo $nurse->soc_sec; ?></textarea>
<input type="hidden" name="varify_file[soc_sec]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Country of Birth</td>
<td class="verification-label-value"><?php echo $nurse->country_of_birth; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[country_of_birth]" value="country_of_birth">
<textarea name="varify_data[country_of_birth]" style="display: none;"><?php echo $nurse->country_of_birth; ?></textarea>
<input type="hidden" name="varify_file[country_of_birth]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Ethnicity</td>
<td class="verification-label-value"><?php echo $nurse->ethnicity; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[ethnicity]" value="country_of_birth">
<textarea name="varify_data[ethnicity]" style="display: none;"><?php echo $nurse->ethnicity; ?></textarea>
<input type="hidden" name="varify_file[ethnicity]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Height (feet/inches)</td>
<td class="verification-label-value"><?php echo $nurse->height; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Weight ()</td>
<td class="verification-label-value"><?php echo $nurse->weight; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Eye Color</td>
<td class="verification-label-value"><?php echo $nurse->eye_color; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Hair Color</td>
<td class="verification-label-value"><?php echo $nurse->hair_color; ?></td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Primary Languages Spoke</td>
<td class="verification-label-value"><?php echo $nurse->primary_langualge; ?></td>
<td class="verification-checked"></td>
</tr>
<tr><td colspan="3" class="verification-tab">Contact Info</td></tr>
<tr>
<td class="verification-label">Permanent Address</td>
<td class="verification-label-value"><?php echo $nurse->address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Permanent_Address]" value="Permanent_Address">
<textarea name="varify_data[Permanent_Address]" style="display: none;"><?php echo $nurse->address1.','.$nurse->direction1.','.$nurse->state1_name.','.$nurse->county1.','.$nurse->zipcode1; ?></textarea>
<input type="hidden" name="varify_file[Permanent_Address]" value="">
</td>
</tr>
<tr>
<td class="verification-label">State Verification</td>
<td class="verification-label-value"><?php echo $nurse->state1_name; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[state_verification]" value="true">
</td>
</tr>
<tr>
<td class="verification-label">Alternate Mailing Address</td>
<td class="verification-label-value"><?php echo $nurse->address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Alternate_Mailing_Address]" value="Alternate Mailing Address">
<textarea name="varify_data[Alternate_Mailing_Address]" style="display: none;"><?php echo $nurse->address2.','.$nurse->direction2.','.$nurse->state2_name.','.$nurse->county2.','.$nurse->zipcode2; ?></textarea>
<input type="hidden" name="varify_file[Alternate_Mailing_Address]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Alternative Mobile No.</td>
<td class="verification-label-value"><?php echo $nurse->phone2; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Alternative_Mobile_No]" value="Alternative Mobile No">
<textarea name="varify_data[Alternative_Mobile_No]" style="display: none;"><?php echo $nurse->phone2; ?></textarea>
<input type="hidden" name="varify_file[Alternative_Mobile_No]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Other Contact</td>
<td class="verification-label-value"><?php echo $nurse->other_contact; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Other_Contact]" value="Other Contact">
<textarea name="varify_data[Other_Contact]" style="display: none;"><?php echo $nurse->other_contact; ?></textarea>
<input type="hidden" name="varify_file[Other_Contact]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Alternative Email</td>
<td class="verification-label-value"><?php echo $nurse->alternative_email; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Alternative_Email]" value="Alternative Email">
<textarea name="varify_data[Alternative_Email]" style="display: none;"><?php echo $nurse->alternative_email; ?></textarea>
<input type="hidden" name="varify_file[Alternative_Email]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Preferred Contact Method</td>
<td class="verification-label-value"><?php echo $nurse->preferred_contact; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Preferred_Contact_Method]" value="Preferred Contact Method">
<textarea name="varify_data[Preferred_Contact_Method]" style="display: none;"><?php echo $nurse->preferred_contact; ?></textarea>
<input type="hidden" name="varify_file[Preferred_Contact_Method]" value="">
</td>
</tr>
<tr><td colspan="3" class="verification-tab">Basic Documents</td></tr>
<tr>
<td class="verification-label">School Certificate Verification </td>
<td class="verification-label-value">
</td class="verification-label-value">
<td class="verification-checked">
<input type="checkbox" name="varify_field[school_certificate]" value="true">
</td>
</tr>
<tr>
<td class="verification-label">Photo </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_PHOTOCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_PHOTOCODE_][0]; ?>">View</a>
</td class="verification-label-value">
<td class="verification-checked">
<input type="checkbox" name="varify_field[Photo]" value="Photo">
<textarea name="varify_data[Photo]" style="display: none;"><?php echo $documentsrem[_DOC_PHOTOCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Photo]" value="<?php echo $documentsarr[_DOC_PHOTOCODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Citizen Documentation </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CTZCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CTZCODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Citizenship_Document]" value="Citizenship Document">
<textarea name="varify_data[Citizenship_Document]" style="display: none;"><?php echo $documentsrem[_DOC_CTZCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Citizenship_Document]" value="<?php echo $documentsarr[_DOC_CTZCODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Social Security Card </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_SSCCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_SSCCODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Social_Security_Card]" value="Citizenship Document">
<textarea name="varify_data[Social_Security_Card]" style="display: none;"><?php echo $documentsrem[_DOC_SSCCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Social_Security_Card]" value="<?php echo $documentsarr[_DOC_SSCCODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">State or Federal issued ID </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_SFICODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_SFICODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[State_or_Federal_issued_ID]" value="State or Federal issued ID ">
<textarea name="varify_data[State_or_Federal_issued_ID]" style="display: none;"><?php echo $documentsrem[_DOC_SFICODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[State_or_Federal_issued_ID]" value="<?php echo $documentsarr[_DOC_SFICODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Malpractice Insurance Policy </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_MICCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_MICCODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Malpractice_Insurance_Policy]" value="Malpractice Insurance Policy">
<textarea name="varify_data[Malpractice_Insurance_Policy]" style="display: none;"><?php echo $documentsrem[_DOC_MICCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Malpractice_Insurance_Policy]" value="<?php echo $documentsarr[_DOC_MICCODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Resume </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RESUMECODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_RESUMECODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Resume]" value="Resume">
<textarea name="varify_data[Resume]" style="display: none;"><?php echo $documentsrem[_DOC_RESUMECODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Resume]" value="<?php echo $documentsarr[_DOC_RESUMECODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">NPI Document </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_NPICODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_NPICODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[NPI_Document]" value="NPI Document">
<textarea name="varify_data[NPI_Document]" style="display: none;"><?php echo $documentsrem[_DOC_NPICODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[NPI_Document]" value="<?php echo $documentsarr[_DOC_NPICODE_][0]; ?>">
</td>
</tr>
<tr><td colspan="3" class="verification-tab">Medical Documents</td></tr>
<!-- <tr>
<td class="verification-label">Rubella </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RUBELLACODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_RUBELLACODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Rubella]" value="Rubella">
<textarea name="varify_data[Rubella]" style="display: none;"><?php echo $documentsrem[_DOC_RUBELLACODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Rubella]" value="<?php echo $documentsarr[_DOC_RUBELLACODE_][0]; ?>">
</td>
</tr> -->
<!-- <tr>
<td class="verification-label">Ruboella </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_RUBOELLACODE_][0]; ?>
<a class="" target="_blank" href="<?php echo $documentsarr[_DOC_RUBOELLACODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Ruboella]" value="Ruboella">
<textarea name="varify_data[Ruboella]" style="display: none;"><?php echo $documentsrem[_DOC_RUBOELLACODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Ruboella]" value="<?php echo $documentsarr[_DOC_RUBOELLACODE_][0]; ?>">
</td>
</tr> -->
<tr>
<td class="verification-label">Annual Employee Health </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_EHA_CODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_EHA_CODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Annual_Employee_Health]" value="Annual Employee Health">
<textarea name="varify_data[Annual_Employee_Health]" style="display: none;"><?php echo $documentsrem[_DOC_EHA_CODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Annual_Employee_Health]" value="<?php echo $documentsarr[_DOC_EHA_CODE_][0]; ?>">
</td>
</tr>
<tr>
<!-- <td class="verification-label">PPD </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_PPDCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_PPDCODE_][0]; ?>">View</a>
</td> -->
<!-- <td class="verification-checked">
<input type="checkbox" name="varify_field[PPD]" value="PPD">
<textarea name="varify_data[PPD]" style="display: none;"><?php echo $documentsrem[_DOC_PPDCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[PPD]" value="<?php echo $documentsarr[_DOC_PPDCODE_][0]; ?>">
</td> -->
</tr>
<tr>
<td class="verification-label">Drug Screen </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_DRUG_SCREENINGCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_DRUG_SCREENINGCODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Drug_Screen]" value="Drug Screen">
<textarea name="varify_data[Drug_Screen]" style="display: none;"><?php echo $documentsrem[_DOC_DRUG_SCREENINGCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Drug_Screen]" value="<?php echo $documentsarr[_DOC_DRUG_SCREENINGCODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Flu Vaccine </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_FLU_VACCINECODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_FLU_VACCINECODE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Flu_Vaccine]" value="Flu Vaccine">
<textarea name="varify_data[Flu_Vaccine]" style="display: none;"><?php echo $documentsrem[_DOC_FLU_VACCINECODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Flu_Vaccine]" value="<?php echo $documentsarr[_DOC_FLU_VACCINECODE_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">Covid Report </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_COVID_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_COVID_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Covid_Report ]" value="Covid Report">
<textarea name="varify_data[Covid_Report]" style="display: none;"><?php echo $documentsrem[_DOC_COVID_][0]; ?></textarea>
<input type="hidden" name="varify_file[Covid_Report]" value="<?php echo $documentsarr[_DOC_COVID_][0]; ?>">
</td>
</tr>
<tr>
<td class="verification-label">CPR Report</td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CPR_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CPR_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[CPR_Report ]" value="CPR Report">
<textarea name="varify_data[CPR_Report]" style="display: none;"><?php echo $documentsrem[_DOC_CPR_][0]; ?></textarea>
<input type="hidden" name="varify_file[CPR_Report]" value="<?php echo $documentsarr[_DOC_CPR_][0]; ?>">
</td>
</tr>
<tr>
<!-- <td class="verification-label">Chest X-ray </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_CHEST_X_RAYCODE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_CHEST_X_RAYCODE_][0]; ?>">View</a>
</td> -->
<!-- <td class="verification-checked">
<input type="checkbox" name="varify_field[Chest_X_ray]" value="Chest X-ray">
<textarea name="varify_data[Chest_X_ray]" style="display: none;"><?php echo $documentsrem[_DOC_CHEST_X_RAYCODE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Chest_X_ray]" value="<?php echo $documentsarr[_DOC_CHEST_X_RAYCODE_][0]; ?>">
</td> -->
</tr>
<tr><td colspan="3" class="verification-tab">Licenses & Certifications</td></tr>
<tr>
<td class="verification-label">Licence </td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_TRAINING_LICENCE_][0]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_TRAINING_LICENCE_][0]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Licence]" value="Licence">
<textarea name="varify_data[Licence]" style="display: none;"><?php echo $documentsrem[_DOC_TRAINING_LICENCE_][0]; ?></textarea>
<input type="hidden" name="varify_file[Licence]" value="<?php echo $documentsarr[_DOC_TRAINING_LICENCE_][0]; ?>">
</td>
</tr>
<!-- <tr><td colspan="3" class="verification-tab">Training Documents</td></tr> -->
<?php for($i=0;$i<$traing_doc_count;$i++){ ?>
<tr>
<td class="verification-label">Aditional Documents</td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_TRAININGCODE_][$i]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_TRAININGCODE_][$i]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Training_Documents<?php echo $i;?>]" value="Training Documents<?php echo $i;?>">
<textarea name="varify_data[Training_Documents<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_DOC_TRAININGCODE_][$i]; ?></textarea>
<input type="hidden" name="varify_file[Training_Documents<?php echo $i;?>]" value="<?php echo $documentsarr[_DOC_TRAININGCODE_][$i]; ?>">
</td>
</tr>
<?php } ?>
<tr><td colspan="3" class="verification-tab">Other Documents</td></tr>
<?php for($i=0;$i<$other_doc_count;$i++){ ?>
<tr>
<td class="verification-label">Documents Details</td>
<td class="verification-label-value"><?php echo $documentsrem[_DOC_OTHERCODE_][$i]; ?>
<a class="" target="_blank" href="<?php echo base_url(); ?><?php echo $documentsarr[_DOC_OTHERCODE_][$i]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Other_Documents<?php echo $i;?>]" value="Other Documents<?php echo $i;?>">
<textarea name="varify_data[Other_Documents<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_DOC_OTHERCODE_][$i]; ?></textarea>
<input type="hidden" name="varify_file[Other_Documents<?php echo $i;?>]" value="<?php echo $documentsarr[_DOC_OTHERCODE_][$i]; ?>">
</td>
</tr>
<?php } ?>
<tr><td colspan="3" class="verification-tab">Employment Info</td></tr>
<tr>
<td class="verification-label">Availability(Borough)</td>
<td class="verification-label-value"><?php echo $nurse->avail_borough; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Availability_Borough]" value="Availability(Borough)">
<textarea name="varify_data[Availability_Borough]" style="display: none;"><?php echo $nurse->avail_borough; ?></textarea>
<input type="hidden" name="varify_file[Availability_Borough]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Availability(Time Slot)</td>
<td class="verification-label-value"><?php echo $nurse->avail_time_slot; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Availability_Time_Slot]" value="Availability(Time Slot)">
<textarea name="varify_data[Availability_Time_Slot]" style="display: none;"><?php echo $nurse->avail_time_slot; ?></textarea>
<input type="hidden" name="varify_file[Availability_Time_Slot]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Availability(Stay)</td>
<td class="verification-label-value"><?php echo $nurse->availability_stay; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Availability_Stay]" value="Availability(Stay)">
<textarea name="varify_data[Availability_Stay]" style="display: none;"><?php echo $nurse->availability_stay; ?></textarea>
<input type="hidden" name="varify_file[Availability_Stay]" value="">
</td>
</tr>
<!-- <tr>
<td class="verification-label">Availability and other Notes</td>
<td class="verification-label-value"><?php echo $nurse->availability_note; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Availability_and_other_Notes]" value="Availability and other Notes">
<textarea name="varify_data[Availability_and_other_Notes]" style="display: none;"><?php echo $nurse->availability_note; ?></textarea>
<input type="hidden" name="varify_file[Availability_and_other_Notes]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Referral Source</td>
<td class="verification-label-value"><?php echo $nurse->ref_source; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Referral_Source]" value="Referral Source">
<textarea name="varify_data[Referral_Source]" style="display: none;"><?php echo $nurse->ref_source; ?></textarea>
<input type="hidden" name="varify_file[Referral_Source]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Profession</td>
<td class="verification-label-value"><?php echo $nurse->profesonal; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Profession]" value="Profession">
<textarea name="varify_data[Profession]" style="display: none;"><?php echo $nurse->profesonal; ?></textarea>
<input type="hidden" name="varify_file[Profession]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Employee Type</td>
<td class="verification-label-value"><?php echo $nurse->employee_type; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Employee_Type]" value="Employee Type">
<textarea name="varify_data[Employee_Type]" style="display: none;"><?php echo $nurse->employee_type; ?></textarea>
<input type="hidden" name="varify_file[Employee_Type]" value="">
</td>
</tr> -->
<tr>
<td class="verification-label">Application Date</td>
<td class="verification-label-value"><?php echo $nurse->application_date; ?>
</td>
<td class="verification-checked"></td>
</tr>
<tr>
<td class="verification-label">Pre Employment Skill Competency</td>
<td class="verification-label-value"><?php echo $nurse->pre_emp_skill; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Pre_Employment_Skill_Competency]" value="Pre Employment Skill Competency">
<textarea name="varify_data[Pre_Employment_Skill_Competency]" style="display: none;"><?php echo $nurse->pre_emp_skill; ?></textarea>
<input type="hidden" name="varify_file[Pre_Employment_Skill_Competency]" value="">
</td>
</tr>
<tr>
<td class="verification-label">PCA Registry Number</td>
<td class="verification-label-value"><?php echo $nurse->PCA_Registry_Number; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[PCA_Registry_Number]" value="PCA Registry Number">
<textarea name="varify_data[PCA_Registry_Number]" style="display: none;"><?php echo $nurse->PCA_Registry_Number; ?></textarea>
<input type="hidden" name="varify_file[PCA_Registry_Number]" value="">
</td>
</tr>
<!-- <tr>
<td class="verification-label">NPI Number</td>
<td class="verification-label-value"><?php echo $nurse->NPI_Number; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[NPI_Number]" value="NPI Number">
<textarea name="varify_data[NPI_Number]" style="display: none;"><?php echo $nurse->NPI_Number; ?></textarea>
<input type="hidden" name="varify_file[NPI_Number]" value="">
</td>
</tr> -->
<tr><td colspan="3" class="verification-tab">Reference</td></tr>
<tr>
<td class="verification-label">Personal References Name</td>
<td class="verification-label-value"><?php echo $nurse->Personal_References_Name; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Personal_References_Name]" value="Personal References Name">
<textarea name="varify_data[Personal_References_Name]" style="display: none;"><?php echo $nurse->Personal_References_Name; ?></textarea>
<input type="hidden" name="varify_file[Personal_References_Name]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Personal References Address</td>
<td class="verification-label-value"><?php echo $nurse->Personal_References_Address; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Personal_References_Address]" value="Personal References Address">
<textarea name="varify_data[Personal_References_Address]" style="display: none;"><?php echo $nurse->Personal_References_Address; ?></textarea>
<input type="hidden" name="varify_file[Personal_References_Address]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Personal References Telephone</td>
<td class="verification-label-value"><?php echo $nurse->Personal_References_Telephone; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Personal_References_Telephone]" value="Personal References Telephone">
<textarea name="varify_data[Personal_References_Telephone]" style="display: none;"><?php echo $nurse->Personal_References_Telephone; ?></textarea>
<input type="hidden" name="varify_file[Personal_References_Telephone]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Profesonal References Name</td>
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Name; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Profesonal_References_Name]" value="Profesonal References Name">
<textarea name="varify_data[Profesonal_References_Name]" style="display: none;"><?php echo $nurse->Profesonal_References_Name; ?></textarea>
<input type="hidden" name="varify_file[Profesonal_References_Name]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Profesonal References Address</td>
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Address; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Profesonal_References_Address]" value="Profesonal References Address">
<textarea name="varify_data[Profesonal_References_Address]" style="display: none;"><?php echo $nurse->Profesonal_References_Address; ?></textarea>
<input type="hidden" name="varify_file[Profesonal_References_Address]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Profesonal References Telephone</td>
<td class="verification-label-value"><?php echo $nurse->Profesonal_References_Telephone; ?>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Profesonal_References_Telephone]" value="Profesonal References Telephone">
<textarea name="varify_data[Profesonal_References_Telephone]" style="display: none;"><?php echo $nurse->Profesonal_References_Telephone; ?></textarea>
<input type="hidden" name="varify_file[Profesonal_References_Telephone]" value="">
</td>
</tr>
<!-- <tr><td colspan="3" class="verification-tab">Malpractice Insurance Policy</td></tr>
<tr>
<td class="verification-label">Carrier Name</td>
<td class="verification-label-value"><?php echo $nurse->Carrier_Name; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Carrier_Name]" value="Carrier Name">
<textarea name="varify_data[Carrier_Name]" style="display: none;"><?php echo $nurse->Carrier_Name; ?></textarea>
<input type="hidden" name="varify_file[Carrier_Name]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Policy Number</td>
<td class="verification-label-value"><?php echo $nurse->Policy_Number; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Policy_Number]" value="Policy Number">
<textarea name="varify_data[Policy_Number]" style="display: none;"><?php echo $nurse->Policy_Number; ?></textarea>
<input type="hidden" name="varify_file[Policy_Number]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Expiration Date</td>
<td class="verification-label-value"><?php echo $nurse->Expiration_Date; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Expiration_Date]" value="Expiration Date">
<textarea name="varify_data[Expiration_Date]" style="display: none;"><?php echo $nurse->Expiration_Date; ?></textarea>
<input type="hidden" name="varify_file[Expiration_Date]" value="">
</td>
</tr>
<tr><td colspan="3" class="verification-tab">Automobile Insurance Policy</td></tr>
<tr>
<td class="verification-label">Automobile Policy Holder Name</td>
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Holder_Name; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Automobile_Policy_Holder_Name]" value="Automobile Policy Holder Name">
<textarea name="varify_data[Automobile_Policy_Holder_Name]" style="display: none;"><?php echo $nurse->Automobile_Policy_Holder_Name; ?></textarea>
<input type="hidden" name="varify_file[Automobile_Policy_Holder_Name]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Automobile Policy Number</td>
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Number; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Automobile_Policy_Number]" value="Automobile Policy Number">
<textarea name="varify_data[Automobile_Policy_Number]" style="display: none;"><?php echo $nurse->Automobile_Policy_Number; ?></textarea>
<input type="hidden" name="varify_file[Automobile_Policy_Number]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Automobile Policy Expiration Date</td>
<td class="verification-label-value"><?php echo $nurse->Automobile_Policy_Expiration_Date; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Automobile_Policy_Expiration_Date]" value="Automobile Policy Expiration Date">
<textarea name="varify_data[Automobile_Policy_Expiration_Date]" style="display: none;"><?php echo $nurse->Automobile_Policy_Expiration_Date; ?></textarea>
<input type="hidden" name="varify_file[Automobile_Policy_Expiration_Date]" value="">
</td>
</tr>
<tr>
<td class="verification-label">CPR Certification (Expiration Date)</td>
<td class="verification-label-value"><?php echo $nurse->CPR_Certification_Expiration_Date; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[CPR_Certification_Expiration_Date]" value="CPR Certification (Expiration Date)">
<textarea name="varify_data[CPR_Certification_Expiration_Date]" style="display: none;"><?php echo $nurse->CPR_Certification_Expiration_Date; ?></textarea>
<input type="hidden" name="varify_file[CPR_Certification_Expiration_Date]" value="">
</td>
</tr> -->
<tr><td colspan="3" class="verification-tab">Additional Certifications</td></tr>
<?php for($i=0;$i<$additional_certificate_count;$i++){ ?>
<tr>
<td class="verification-label">Additional Certificate Details</td>
<td class="verification-label-value"><?php echo $documentsrem[_ADDL_CERTIFICATE_][$i]; ?>
<a class="" target="_blank" href="<?php echo $documentsarr[_ADDL_CERTIFICATE_][$i]; ?>">View</a>
</td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Additional_Certificate_Details<?php echo $i;?>]" value="Additional Certificate Details<?php echo $i;?>">
<textarea name="varify_data[Additional_Certificate_Details<?php echo $i;?>]" style="display: none;"><?php echo $documentsrem[_ADDL_CERTIFICATE_][$i]; ?></textarea>
<input type="hidden" name="varify_file[Additional_Certificate_Details<?php echo $i;?>]" value="<?php echo $documentsarr[_ADDL_CERTIFICATE_][$i]; ?>">
</td>
</tr>
<?php } ?>
<tr><td colspan="3" class="verification-tab">Emergency Contact</td></tr>
<tr>
<td class="verification-label">Name</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Name; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Name]" value="Emergency Contact Name">
<textarea name="varify_data[Emergency_Contact_Name]" style="display: none;"><?php echo $nurse->Emergency_Contact_Name; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Name]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Relationship</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Relationship; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Relationship]" value="Emergency Contact Relationship">
<textarea name="varify_data[Emergency_Contact_Relationship]" style="display: none;"><?php echo $nurse->Emergency_Contact_Relationship; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Relationship]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Address</td>
<td class="verification-label-value"><?php
$x = json_decode($nurse->Emergency_Contact_Address);
echo $x->Emergency_Contact_Address.','. $x->Emergency_Contact_zipcode;
?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Address]" value="Emergency Contact Address">
<textarea name="varify_data[Emergency_Contact_Address]" style="display: none;"><?php echo $nurse->Emergency_Contact_Address; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Address]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Telephone</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Telephone; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Telephone]" value="Emergency Contact Telephone">
<textarea name="varify_data[Emergency_Contact_Telephone]" style="display: none;"><?php echo $nurse->Emergency_Contact_Telephone; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Telephone]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Cellphone</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Cellphone; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Cellphone]" value="Emergency Contact Cellphone">
<textarea name="varify_data[Emergency_Contact_Cellphone]" style="display: none;"><?php echo $nurse->Emergency_Contact_Cellphone; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Cellphone]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Other</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Other; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Other]" value="Emergency Contact Other">
<textarea name="varify_data[Emergency_Contact_Other]" style="display: none;"><?php echo $nurse->Emergency_Contact_Other; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Other]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Email</td>
<td class="verification-label-value"><?php echo $nurse->Emergency_Contact_Email; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Emergency_Contact_Email]" value="Emergency Contact Email">
<textarea name="varify_data[Emergency_Contact_Email]" style="display: none;"><?php echo $nurse->Emergency_Contact_Email; ?></textarea>
<input type="hidden" name="varify_file[Emergency_Contact_Email]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Lives with patient</td>
<td class="verification-label-value"><?php echo $nurse->live_with_patient; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[live_with_patient]" value="Lives with patient">
<textarea name="varify_data[live_with_patient]" style="display: none;"><?php echo $nurse->live_with_patient; ?></textarea>
<input type="hidden" name="varify_file[live_with_patient]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Have Keys or access to home</td>
<td class="verification-label-value"><?php echo $nurse->have_key; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[have_key]" value="Have Keys or access to home">
<textarea name="varify_data[have_key]" style="display: none;"><?php echo $nurse->have_key; ?></textarea>
<input type="hidden" name="varify_file[have_key]" value="">
</td>
</tr>
<tr><td colspan="3" class="verification-tab">Caregiver Preference</td></tr>
<!-- <tr>
<td class="verification-label">Religious Preferences</td>
<td class="verification-label-value"><?php echo $nurse->Religious_Preferences; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Religious_Preferences]" value="Religious Preferences">
<textarea name="varify_data[Religious_Preferences]" style="display: none;"><?php echo $nurse->Religious_Preferences; ?></textarea>
<input type="hidden" name="varify_file[Religious_Preferences]" value="">
</td>
</tr> -->
<tr>
<td class="verification-label">Preffered Gender</td>
<td class="verification-label-value"><?php echo $nurse->Preffered_Gender; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Preffered_Gender]" value="Religious Gender">
<textarea name="varify_data[Preffered_Gender]" style="display: none;"><?php echo $nurse->Preffered_Gender; ?></textarea>
<input type="hidden" name="varify_file[Preffered_Gender]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Notes</td>
<td class="verification-label-value"><?php echo $nurse->Notes; ?></td>
<td class="verification-checked">
<input type="checkbox" name="varify_field[Notes]" value="Notes">
<textarea name="varify_data[Notes]" style="display: none;"><?php echo $nurse->Notes; ?></textarea>
<input type="hidden" name="varify_file[Notes]" value="">
</td>
</tr>
<tr>
<td class="verification-label">Accept</td>
<td class="verification-label-value"></td>
<td class="verification-checked">
<input type="radio" id="acceptYes" name="acceptCaregiver" value="YES" checked>
<label for="acceptYes">YES</label>
<input type="radio" id="acceptNo" name="acceptCaregiver" value="NO">
<label for="acceptNo">NO</label>
</td>
</tr>
<tr id="rejectionNote" style="display:none;" >
<td class="verification-label">Rejection Note</td>
<td class="verification-checked" colspan="2" width="100%">
<textarea name="rejectionNote"></textarea>
</td>
</tr>
</tbody>
</table>
</div>
<div class="col-md-12 text-center">
<button type="submit" id="submit_btn" name="submit" style="display:none" class="btn btn-info"><?php echo lang('submit'); ?></button>
<!-- <button id="checkAll" type="button" class="btn btn-info"><?php echo lang('check all'); ?></button> -->
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
</div>
<script>
$("input[type='checkbox']").change(function(){
// alert("hii");
var a = $("input[type='checkbox']");
// if((a.length - 2)== a.filter(":checked").length){
if((a.length)== a.filter(":checked").length){
//alert('all checked');
$('#submit_btn').show();
}else{
$('#submit_btn').hide();
}
});
</script>
<script>
$("#checkAll").click(function(){
if (! $('input:checkbox').is('checked')) {
$('input:checkbox').attr('checked','checked');
} else {
$('input:checkbox').removeAttr('checked');
}
});
</script>
<script type="text/javascript">
/* future date dob not accept */
$(document).ready(function() {
// alert("dateSec");
var todaysDate = new Date(); // Gets today's date
// Max date attribute is in "YYYY-MM-DD". Need to format today's date accordingly
var year = todaysDate.getFullYear(); // YYYY
var month = ("0" + (todaysDate.getMonth() + 1)).slice(-2); // MM
var day = ("0" + todaysDate.getDate()).slice(-2); // DD
var maxDate = (year + "-" + month + "-" + day); // Results in "YYYY-MM-DD" for today's date
// Now to set the max date value for the calendar to be today's date
$('.ftrDate').attr('max', maxDate);
});
function validateAcceptance(){
var acceptCaregiver=$('input[name=acceptCaregiver]:checked').val();
//alert(acceptCaregiver);
var rejectionNote=$("textarea[name=rejectionNote]").val();
//alert(rejectionNote);
if(acceptCaregiver == 'YES')
{
return true;
// if (! $('input:checkbox').is('checked')) {
// return false;
// } else {
// return true;
// }
}
else
{
if(rejectionNote!='')
{
return true;
}
else
{
return false;
}
}
}
$('input[name=acceptCaregiver]').click(function(){
var acceptCaregiver=$(this).val();
//alert(acceptCaregiver);
if(acceptCaregiver=='NO'){
$("#rejectionNote").show();
}else{
$("#rejectionNote").hide();
}
});
</script>
<script>
$("#checkNpi_no").blur(function(){
var npi_no=$("input[name=npi_no]").val();
if(npi_no!=""){
$.ajax({
url:'<?=base_url()?>referral/getNpiData?code='+npi_no,
type :'GET',
dataType: "json",
beforeSend: function() {
$("#npiValid").hide();
$("#npiinValid").hide();
$("#npiNoValidating").show();
$("#npivalidateTab").show();
$(".check-npi").hide();
$("#approve_submitBtn").prop('disabled', true);
},
success:function(data){
console.log(data);
$('#phymdfName').val(data.fname);
if(data.license)
{
$("#npivalidate").val('valid');
$("#npiValid").show();
$("#npiinValid").hide();
$("#npiNoValidating").hide();
$("#approve_submitBtn").prop('disabled', false);
}
else
{
$("#npivalidate").val('invalid');
$("#npiValid").hide();
$("#npiinValid").show();
$("#npiNoValidating").hide();
$(".check-npi").show();
$("#approve_submitBtn").prop('disabled', true);
}
}
});
}else{
Swal.fire({
position: 'center',
icon: 'error',
title: 'Please enter npi no.',
showConfirmButton: false,
timer: 1500
});
}
});
function isNumberKey(evt) {
var charCode = (evt.which) ? evt.which : evt.keyCode;
if (charCode > 31 && (charCode < 48 || charCode > 57))
return false;
return true;
}
</script>
<!--main content end-->
<!--footer start-->
<script>
$(document).ready(function() {
$(".citizen_depending").click(function(){
var target_val = $(this).val();
var open_value = $(this).attr("open_value");
var change_required_to = $(this).attr("change_required_to");
var yesDocumentsOption= '<option value="">Select</option>'
+'<option value="Birth Certificate">Birth Certificate</option>'
+'<option value="State ID">State ID</option>'
+'<option value="Citizenship Certificate">Citizenship Certificate</option>'
+'<option value="US Passport">US Passport</option>';
var noDocumentsOption= '<option value="">Select</option>'
+'<option value="Permanent Resident Card">Permanent Resident Card</option>'
+'<option value="Employment Authorization Card">Employment Authorization Card</option>'
+'<option value="Valid Work Visa">Valid Work Visa</option>';
if($('#remain_permanentlyyes').is(':checked')){
noDocumentsOption += '<option value="Foreign Passport with I-94 Stamp">Foreign Passport with I-94 Stamp</option>';
}
if (target_val == open_value){
$("#"+change_required_to).hide();
$("#documents_type").html(yesDocumentsOption);
$(".documents_expire_date_container").hide()
$("#documents_expire_date").removeAttr('required');
$("#documents_expire_date").val('');
$("#uscis").val('');
$(".docExpLvl").removeClass("required-field");
}else{
$("#documents_expire_date").val('');
$("#uscis").val('');
$("#"+change_required_to).show();
$("#documents_type").html(noDocumentsOption);
$(".documents_expire_date_container").show();
}
lookingForCitizenYes();
// checkBasicCheckList();
});
});
function lookingForCitizenYes(){
$(document).ready(function(){
if(!$('#citizenyes').is(':checked')){
$(".citizen-yes-state-list").hide();
$(".citizen-yes-state-list").children("label").removeClass("required-field");
$(".citizen-yes-state-list").children("select").prop("required",false);
}
});
}
$(".activate_depending").click(function(){
var target_val = $(this).val();
var open_value = $(this).attr("open_value");
var change_required_to = $(this).attr("change_required_to");
var required_field = $(this).attr("required_field");
//alert(change_required_to);
if (target_val == open_value)
{
$("#"+change_required_to).show();
$("#"+required_field).attr("required","required");
}
else
{
$("#"+change_required_to).hide();
$("#"+required_field).removeAttr("required");
}
checkBasicCheckList();
});
function checkBasicCheckList(){
var citizen=$('input[name=citizen]:checked').val();
var remain_permanently=$('input[name=remain_permanently]:checked').val();
var authorization_to_work=$('input[name=authorization_to_work]:checked').val();
if((citizen==true) || (remain_permanently==true) || (authorization_to_work==true)){
$("#basic_submit_btn").removeAttr('disabled');
}else{
$('#basic_submit_btn').prop("disabled", true);
}
}
$('.criminal_convictions').click(function(){
var inputValue = $(this).attr("value");
if(inputValue == true)
{
$("#criminal_convictions_details").show();
$("#criminal_convictions_details_field").attr("required","required");
}
else{
$("#criminal_convictions_details").hide();
$("#criminal_convictions_details_field").removeAttr("required");
}
checkBasicCheckList();
});
</script>
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